Many of the recent overdose deaths in London were preventable

Of the many harms that are associated with illicit drug use, one has been overshadowing the rest in its deadly impact on London's drug-using community. Over the past several months, London has seen a rash of opiate related overdose deaths.  Although most of these fatalities go unnoticed by the wider community, for those of us working in shelters, social service agencies and on the streets with people who use drugs, and indeed for those who themselves use drugs, it seems that not a week goes by without  the sad news of yet another death of someone we know.  Often the news of a death comes the next day as word spreads amongst their friends and acquaintances. By the end of a shift I'll have heard three or four different stories about what happened and sometime it's not entirely clear who has actually died. I'll hear from three people that someone has died, only to run into that person two days later and hear from him that it was someone else who passed.  Sometimes the news comes from a loved-one who took the time during their grief to call and let us know. Sometime someone just stops coming around, and months later we find out why.  But in the six years I've been in the field, I've never seen it like this.

Many of these overdoses have been attributed to Fentanyl, a synthetic opiate that's strength is often misunderstood and grossly under-estimated.

One of the most troubling aspects of this latest string of overdoses and deaths, besides its unrelenting persistence, is the fact that many of these deaths were preventable.  Aside the fact that many of these overdoses could have been avoided in the first place through better education about the drugs people are using, many of the overdoses that do happen simply do not need to have a fatal outcome.  Overdoses often occur in the presence of witnesses who, with some very simple training and very simple means, could save a life.

In many jurisdictions in the U.S, notably Chicago, Wilkes County N.C, New York City, Baltimore and San Francisco, as well as Edmonton here in Canada, a simple and effective solution was found by bringing Naloxone from the realm of emergency medicine into the realm of first aid. This was done by the distributing Naloxone directly to people who use opiate drugs.  Naloxone has been the standard emergency room treatment for opiate overdoses for decades and administering it is relatively simple, being comparable to administering insulin.  Opiate overdoses lead to respiratory depression, in which breathing slows, then stops, often causing brain damage or death.  Naloxone works by crowding the drug off the brain's opiate receptors, allowing breathing to return to normal, usually within minutes and with side effects that are generally no worse with withdrawal symptoms. Naloxone distribution programs aim to put Naloxone into the hands of people, who by virtue of their own drug use are the most likely to witness an overdose and be in a position to help one of their peers should an overdose occur.  Most Naloxone distribution programs include training for those who will be receiving a naloxone prescription which includes recognizing the signs and symptoms of an opiate overdose, understanding the importance of calling 911 and staying with the victim, learning to perform rescue breathing and dispelling the myths of ineffective overdose treatments (such as walking the victim around or immersing them in cold water), using Naloxone properly and education about options for drug treatment.  The risks of using Naloxone as a first aid treatment are minimal, rarely consisting of more than hastening the onset of withdrawal symptoms, which though unpleasant, are much better than dying. With situations where multiple drugs are used and with longer-acting opiates, such as methadone or fentanyl, the return of  respiratory depression can be a concern.  Many Naloxone distribution programs address this concern by providing extra doses of Naloxone and stressing the importance of calling 911 and staying with victim.  In addition to lives saved, early interventions in overdoses with Naloxone could prevent serious complications such as brain damage and reduce costly hospital stays associated with such complications.            

Without this training or the means to turn and overdose around, the only options available is a 911 call and hoping that help arrives in time.  Unfortunately we sometimes hear of instances when calling 911 was delayed due to the belief, right or wrong, that the police would attend the scene and make arrests. The Vancouver Police Department addressed this concern by simply having its officers not attend overdose calls unless EMS specifically requested police presence and making this policy change know to people who use drugs. The VPD policy did not prevent officers from attending calls where an overdose death had occurred in order to collect evidence and included the flexibility of allowing for the policy to be suspended whenever a rash of ODs were detected in order to collect evidence and try to identify the source of the drugs causing the overdoses.  A similar policy in London could result in saved lives and see officers freed up for other calls.  

Some would argue that protecting people who use drugs from the negative consequences of their drug use would decreases their motivation reduce or kick their drug use. They'd argue that it would increases the chances that people who use drugs would feel comfortable taking greater risks and using more if Naloxone were available. This argument implies that somehow drug use is worse than death or injury from overdose or disease.  It implies that keeping the spectre of fatal overdoses and brain damage from overdoses is a legitimate and moral scare tactic; If a person using drugs refuses to get clean and experiences such harms or death, somehow those consequences are deserved and will act as an example to deter others.  Saving one by writing off another...  It should be noted that there is little evidence to suggest that the risk of overdose is an effective deterrent to someone experiencing opiate withdrawal. Conversely, rather than increasing their drug use or avoiding drug treatment after taking training in Naloxone use, many program participants in San Francisco reported a significant decrease in injection drug use and the group showed a small increase in drug treatment uptake.

It seems to be a widely held belief that someone has to hit rock bottom before they can change their life. However, treatment is not an option for the dead. For many, their bottom happens to be a fatal overdose which in many instances is completely preventable. It's time to remind ourselves that everyone who uses drugs is someone's son or daughter, and often someone's brother or sister, mother or father. It's time to resolve that no matter what our community's views on drug use and no matter what choices has led someone to their drug use, that no life is worthless. It's time to morn the dead and fight like hell for the living. 

Michael McGregor

***note***
I am an outreach worker working for the Unity Project for the Relief of Homelessness in London doing mostly street-level needle distribution on behalf of the London Community Addictions Response Strategy (London CAReS).  I've been working with the Unity Project since August of 2003 and with London CAReS since October of 2007.

Portions of this letter are paraphrased from the Project Lazarus Policy briefing document out of Wilkes County NC available online at: http://www.harmreduction.org/downloads/North%20Carolina%20Naloxone%2007.pdf .

The VPD drug overdose policy is available online at: http://vancouver.ca/police/policeboard/documents/ 0648DrugOverdosePolicy2006Jun14.pdf